Why do family physicians fail to detect renal impairment?

OBJECTIVE: To investigate why many patients with renal impairment (30.7%) were not recognized by their family physicians despite an earlier educational intervention on detecting renal impairment; and to determine whether certain factors related to physicians, patients, or the intervention itself were associated with whether renal impairment was detected. DESIGN: Qualitative approach using grounded theory. SETTING: A Health Service Organization in Ottawa, Ont. PARTICIPANTS: A purposeful sample of six family physicians. METHODS: In semistructured interviews, participants were asked to describe the workup ordered and their decision-making processes for patients in whom they had recently detected renal impairment. They were also asked to evaluate the six components of an educational intervention designed to help them to detect renal impairment. Finally, one patient's chart was reviewed (a chart containing a laboratory report noting an abnormal result for kidney function and having no indication that renal impairment had been recognized) to identify reasons for lack of detection. RESULTS: Most physicians did not investigate every patient with renal impairment (glomerular filtration rate of < 78 mL/min) in the same way because they took individual patient factors into consideration. Reasons for not detecting renal impairment were "managed differently" or "missed," with the former being the most common. The educational intervention physicians remembered most often was chart rounds, and these were viewed as helpful. "Missed" cases were more often deliberately managed differently than unintentionally not detected. CONCLUSION: Physicians used various approaches to detect and manage renal impairment despite interventions that recommended a consistent procedure.

Detection of chronic kidney disease with laboratory reporting of estimated glomerular filtration rate and an educational program.

BACKGROUND: Serum creatinine concentration is an inadequate screening test for chronic kidney disease, especially in elderly patients. We hypothesized that laboratory reporting of estimated glomerular filtration rate (GFR) accompanied with an educational intervention would improve recognition of chronic kidney disease (CKD). METHODS: We conducted a before-and-after study at an outpatient family medicine practice. Patients 65 years or older for whom a Cockcroft-Gault GFR could be calculated from their medical record were included. The intervention consisted of automatic reporting of estimated GFR by the hospital laboratory along with an educational intervention directed toward the primary care physicians. The primary outcome was the recognition of CKD (defined as a Cockroft-Gault GFR <60 mL/min [<1.0 mL/s]) by the primary care physician. Factors associated with the recognition of CKD were also determined. RESULTS: The study population comprised 324 patients. Prior to the study intervention, 22.4% of patients with CKD were recognized, which increased to 85.1% after the intervention. Before the intervention, recognition was more likely in male subjects (odds ratio, 4.3; 95% confidence interval, 1.9-9.8) and patients with diabetes (odds ratio, 3.4; 95% confidence interval, 1.6-7.6). These associations were no longer statistically significant after the intervention. CONCLUSION: Laboratory reporting of estimated GFR coupled with an educational program markedly improves the recognition of CKD in the primary care setting.

Daily hemofiltration with a simplified method of delivery.

Observational studies of daily hemodialysis (HD) and intermittent hemofiltration (HF) therapy have been associated with improved outcomes for patients with endstage renal disease. We conducted a prospective study to evaluate the feasibility of daily HF as an alternative to intermittent HD using a simplified HF system (NxStage Medical). Each patient received 1 week of intermittent HD followed by 4 weeks of daily HF. Ringers lactate was used as the initial replacement solution; however, Hemosol LG2/L0 was used subsequently to simplify patient management. Changes in quality of life, nutrition, and laboratory values were assessed. Seven patients have completed 168 HF treatments with Hemosol. Their treatment time on HD was 232 minutes 3 days per week, and 132 minutes on HF 6 days per week. Single pool Kt/V per treatment for HD was 1.69 compared with 0.44 for HF (standard Kt/V 2.38 vs 1.93). Despite these weekly differences in urea clearance, potassium, calcium, phosphate, and nutrition remained stable. Beta-2 microglobulin tended to decline. All parameters of the Kidney Disease Quality of Life Instrument Short Form (KDQOL-SF) either remained stable or improved. In addition, blood pressure declined, allowing for a reduction in the number of antihypertensive medications. In summary, these preliminary data suggest that daily HF with this system is safe, simple, efficacious, and could potentially be used as a home based renal replacement therapy.

Serum creatinine is an inadequate screening test for renal failure in elderly patients.

BACKGROUND: Serum creatinine is the most commonly used screening test for renal failure. We hypothesized that serum creatinine would underestimate the degree of renal failure in elderly people because they have a reduced muscle mass. If so, this would lead to underrecognition and thus suboptimal care of patients with severe renal failure. METHODS: We conducted a retrospective medical record review of all patients 65 years or older in an outpatient academic family medicine practice. The glomerular filtration rate was calculated using the Cockcroft and Gault formula and was used to evaluate the testing characteristics of serum creatinine for the detection of renal failure. RESULTS: We screened 1510 patients, 854 (56.6%) of whom met the inclusion criteria. Renal failure (glomerular filtration rate, 150 micro mol/L) had a sensitivity of 12.6% and a specificity of 99.9% for the detection of renal failure. For the detection of severe renal failure, the sensitivity was 45.5%, with a 99.1% specificity. Only 15 (27.3%) of the 55 patients with severe renal failure were referred to a nephrologist. Moreover, 34 (85%) of the 40 nonreferred patients with severe renal failure were incompletely evaluated regarding the metabolic complications associated with kidney dysfunction. CONCLUSION: Serum creatinine is a poor screening test for renal failure in elderly patients, leading to marked underinvestigation and underrecognition of renal failure in this population.